OPERATION FOR ANTERIOR FISTULAS IN FEMALES AND LATERAL FISTULAS IN MALES AND FEMALES

In female patients with an anterior high-level fistula it is not allowed to divide the sphincter through the an­terior vaginal wall because of the danger of incontinence of wind and faeces. Therefore we have developed a new ope­ration for these patients. Under local or mixed inhalation anesthesia, the fistulous tract on the perineum is excised and then resected (Fig. 81,7) in the usual way (see Fig. 77,1 and 77,2). The wound is painted with a 2 per cent iodine tincture and left unsutured. The rectal lumen is di­lated with a speculum so that the mucosa of the anterior rectal wall is well exposed. The surgeon then dissects free and cuts off a strip of the mucosa 1 —1,5 cm wide and 2—3 cm long (Fig. 81,2), so that the internal fistulous opening is in the centre of the resulting defect. The entire mucosal defect along with the fistulous opening is then closed with catgut by means of small cutting need­les (Fig. 81,3). The sutures are left loose and their ends are grasped with a clamp handed over to the assistant. After 3 or 4 sutures have been applied, rectal specu­lum is withdrawn and the sutures are tied in turn start­ing with the external one, with the assistant drawing out forcibly the first (already tied) suture. Next, Farabeuf re­tractors are used to draw back the lateral rectal wall, while a second row of sutures of thin catgut is placed on the mucosa. After the anterior rectal wall has been sutured, the rectal lumen is slightly (1—1,5 cm) widened with speculum and a posterior sphincterotomy is perfor­med to a depth of 1 cm (Fig. 81,4)*)

*) This posterior sphincterotomy is done in order to provide conditions of rest for the rectal masculature the­reby promoting healing of the sutured anterior rectal wall.

The surgeon now directs his attention to the perineal wound and, following application of 2 per cent iodine tincture, sutures the remainder of the fistulous tract deep within the wound with two layers of catgut (Fig. 81,5). The perineal wound is packed with ointment (its formu­la is given on p. 41). The first dressing is applied on the third, and the second one, on the fifth postoperative day. No rectal packing is applied from the 5th postoperative day onwards. Baths are undertaken beginning with the 8th day, and opium tincture is given during the first ni­ne days postoperatively.

Of 270 patients operated on by us using the above procedure, 94 per cent have been cured.

A variant of this operation, for a fistula passing ex­ternal to the sphincter and having its internal opening in a lateral crypt, is performed in a manner similar to the operation for an anterior fistula in the female, except that the lateral, rather than the anterior, rectal wall is denuded and sutured from the side of the rectum. Sphmc terotomy is performed (Fig. 82,1, 82,2 and 82,3).

Fig. 81. Operation for anterior fistula passing externally to the sphincter in female:

1. Excision of the fistulous tract on the perineum with the wound drawn widely apart by means of retrac­tors.

2. Defect of the mucosa of the anterior rectal wall af­ter excision of a band-like flap. The internal fistulous opening is seen in the centre of the defect.

3. Suturing the defect of anterior rectal wall mucosa together with the internal fistuloug opening.

4. Posterior sphincterotomy with carefully performed widening of the rectal lumen by 1 —1,5 cm.

5. The perineal wound is sutured with two-rows of catgut.

Fig. 82 Operation for fistula passing externally lo the sphincter and having its internal opening in a lateral crypt:

1. Lateral rectal wall is drawn forward by the assis­tant. A strip of mucosa is cut off with a sharp grasping forceps.

2. The internal fistulous opening and the mucosal de­fect are closed with catgut in two layers.